community care of north carolina child health accountable care collaborative (chacc)
TRANSCRIPT
Community Care of North Carolina
Child Health Accountable Care Collaborative (CHACC)
Key Goals
Improve access to, quality of, and coordination of care
By doing so, decrease the cost of care.
Community Care of NC
Statewide primary care medical home & care management system
Rests on foundation of Carolina Access Medicaid in which Medicaid patients are linked to a primary care home
Provides resources to improve access to, quality of and coordination of care across the different segments of the local health care system and decrease cost of care
Private-public partnership (all savings stay in NC)
Provides ready access to data
Community based, locally driven, provider led
Local Networks
14 local Networks across all 100 NC counties with more than 4500 Primary Care Physicians (1360 medical homes)
Over 1.4 million Medicaid enrollees, including dual Medicare/Medicaid and Health Choice enrollees
Local Networks Are non-profit organizations
Provide resources to primary care homes to better manage Medicaid population
Join public and private sector primary care homes with other segments of the health care system (e.g. hospitals, health departments, mental health agencies, social services) to create local systems of care
Utilize local multi-disciplinary RN and SW care managers, pharmacists, psychiatrists, obstetricians, medical directors
Pilot potential solutions, share best practices
Are capable of and accountable for managing recipient care
Main Program Activities
Chronic Disease Management Initiatives (e.g. Asthma, Diabetes)
Chronic Care Initiative
Hospital Transition Care
Quality Improvement Initiatives
Emergency Department Utilization
Chronic Pain Initiative
Integration of Physical and Mental Health
Prevention Initiatives
Pharmacy Initiatives
Palliative Care
Access to Primary Care
Support of IT Initiatives
High Risk Pregnancy Care Management
Key program Asset- Access to dataInformatics Center
Medicaid claims data
Utilization (ED, Hospitalizations)
Providers (Primary Care, Mental Health, Specialists)
Diagnoses
Medications
Labs
Costs
Individual and Population Level Care Alerts
Reports on high-opportunity patients
Quality Measurement and Feedback Review System
Key program Asset- Access to dataReal Time Data
Hospitalizations
ED visits
Provider Referrals
Patient
Primary Care Home
Multidisciplinary management support
QI Support
Link to local health care system and community resources
Patient
Primary Care Home
Hospital
Behavioral Health
~Specialists~
Public Health
Social Services
Community Resources
Child Health Accountable Care Collaborative (CHACC)CMS Innovations Project
Partnership of Community Care of North Carolina and Children’s Health Care Providers
CHACC
3 year Cooperative Agreement from the CMS Innovations Center to Community Care of North Carolina--July 1, 2012- June 1, 2015
Partnership of CCNC with Children’s Primary Care and Specialty Care Providers; and the Academic Medical Centers and Children’s Tertiary Care Hospitals to improve the health of NC children who have complex and chronic illness
Child Health Accountable Care Collaborative (CHACC)
Partnership with North Carolina’s Children’s Healthcare Providers, North Carolina’s Academic Medical Centers and Tertiary Medical Centers
Community Care of North Carolina
CHACC
Project Director Steve Wegner, MD
Medical DirectorsElizabeth Tilson, MD (CCNC Networks) David Tayloe, MD (Primary
Care) Alan Stiles, MD (Pediatric Subspecialists/Hospitals)
CHACC Integration Workgroup
Program DirectorSherri Branski, RN, MSN, CCM Lynn Guerrant, RN, MS
CCNC Networks/Primary Care ProvidersMedical Home
CCNC Network Care Managers
Pediatric Subspecialists/AMCs/Tertiary Children’s Hospitals
CHACC Lead Care Managers, Care Managers, and Patient Coordinators
Program Goals
Improve the health of NC children with complex chronic illnesses through improved value of care.
Engage primary care providers and pediatric subspecialists across the state to share responsibility and accountability for pediatric primary, subspecialty, and hospital care.
Jointly develop and utilize evidence based guidelines of care for pediatric chronic illnesses with pediatric subspecialists and primary care physicians and actively engage in co-management of these children.
Provide active care management to children under the care of pediatric subspecialists through embedded care managers and patient coordinators at tertiary hospitals and provide a warm hand off to CCNC network care managers.
CHACC
CHACC Care ManagerCCNC Care Managers
Patient Coordinators
CCNC Networks--Medical Home/Primary Care Providers
Pediatric Subspecialists/AMCs/Tertiary Children’s Hospitals
Children with complex, chronic Illnesses
Co-management
Specialty CarePrim
ary C
are
Cost Savings Approaches
Reduce hospitalizations through co-management and active monitoring of disease processes
Improve primary and preventive care for children with chronic illnesses by providing this care in a medical home
Reduce utilization of emergency services and pediatric subspecialists for acute common illnesses for these children
Reduce duplication of laboratory and medical studies through streamlined communication between primary care providers and pediatric subspecialists
Reduce pharmacy costs through formulary utilization and evidence based care
Timeline
Operations plan submitted to CMS, August 8, 2012
Anticipate CMS approval by September 10, 2012
Convene a CHACC Integration Workgroup August 2012
Information sessions and discussion at the NC Pediatric Society Meeting September 2012
Refine target population for intervention August to December, 2012
Hiring and training of care managers and patient coordinators September 2012 to January 2013
September 2012 to June 2013 Consensus Sessions of PCPs and Subspecialists
The Role of the General Pediatrician
David T. Tayloe, Jr., MD, FAAP
Children and Youth with Special Health Care Needs (CYSHCN)
Registry of Patients
Care Plans
Subspecialist Care Coordination
Primary Care Physician Care Coordination
Community Partners
Family Involvement
Goldsboro Pediatrics
15 pediatricians, 7 nurse practitioners, a physician assistant, 2 behavioral health professionals, 1 lactation consultant
4 offices serving children in 7 counties
Electronic Health Record System
2 Community Care of NC AccessCare staff
Community Hospital with Level 2 Neonatal Unit
Innovative Approaches
Children and Youth with Special Health Care Needs in Wayne County
Steering Committee of Family Members of CYSHCN and Community Partners
Goldsboro Pediatrics electronic health record system (secure intranet)
Registry and HIPAA-compliant /FERPA-compliant family consent procedures
Wayne Pediatric CME Series
Category I CME Sessions co-sponsored by the Office of CME at the Brody School of Medicine and Goldsboro Pediatrics
Meets at 7 AM in the private dining area of the hospital cafeteria most every Tuesday morning
Community Partners invited to attend sessions
Wayne Initiative for School Health (WISH)
Goldsboro Pediatrics is the medical home for the students enrolled in the six school-based health centers of WISH
Nurse Practitioner and Physician Assistant, with the help of RN’s, clerical staff, Registered Dietitians, behavioral health professionals provide comprehensive care for many at-risk middle/high school students in Wayne County
Community Care of NC
Care Coordinator and Patient Navigator are based in the main office of Goldsboro Pediatrics
CCNC staff attend CME sessions of the Wayne Pediatric CME Series
CCNC staff work closely with Community Partners
4% of Children
Need continuous care by pediatric subspecialists
Should have care plans/passports developed by their subspecialist teams
Need multiple services at the community level
Need 24/7 access to a physician who has access to the medical records of the child
Quality of Care for Children with Complex Medical Conditions
Guidelines and care plans/passports developed by subspecialists
Electronic communication involving tertiary center specialists and community based generalists
Regular visits with subspecialists and primary care physicians
Family input/electronic communication with physicians
Community partner collaboration coordinated by the community-based medical home
Cost-effectiveness of Care for Children with Complex Conditions
24/7 access to subspecialist and generalist physicians
Avoid unnecessary expensive medications and therapies
Avoid unnecessary hospital emergency department visits
Avoid unnecessary hospital admissions
Shortage of Pediatric Subspecialists
Complex children need a lot of time from their pediatric subspecialists
NC has shortages of most categories of pediatric subspecialists
If these subspecialists are to maximize their time with complex children, general pediatricians must do their part to minimize unnecessary referrals to subspecialists
David T. Tayloe, Jr., MD, FAAP
Goldsboro Pediatrics
2706 Medical Office Place
Goldsboro, NC 27534
919-734-4736
fax 919-580-1017
“The project described was supported by Funding Opportunity Number CMS-1C1-12-0001 from Centers for Medicare and Medicaid Services, Center for Medicare and Medicaid Innovation.”
“Its contents are solely the responsibility of the authors and do not necessarily represent the official views of HHS or any of its agencies.”